This paper describes the rationale and methodology for three exercises used to critically appraise the quality of the two main tools supporting implementation of the care pathway continuous improvement methodology. The Venture care pathway journey quality scorecard and the Venture care pathway paper-document quality scorecard builds a greater understanding of the value provided by different components of content and layout. In addition, the Venture paper care pathway document template provides a basic design guide for teams, based on 20 years of experience in developing, implementing and evaluating care pathway documents.
Purpose: The paper demonstrates the complexities of leadership in a local health-care community across primary and secondary care interface, using the example of a general practitioner (GP) with a special interest role (GPwSI) in dermatology. It focuses on how the service will develop and how it could be achieved. Design: Various models and theories about change management were consulted focusing particularly on the goals of the local health-care economy, resources available and environment/contextual surroundings. Practical implications: Primary care trusts (PCTs), acute trusts and clinicians need to work collaboratively to achieve an integrated, flexible care pathway, so that patients and the PCTs can be assured of an efficient and good quality service. Conflicts between primary and secondary care dermatology services are not sustainable for a long period. Originality: The Government's agenda is a shift of care closer to people's homes, so PCTs do need to be aware of what they wish to commission, and consider moving traditional hospital-based facilities into community settings, such as walk-in centres, polyclinics and large health centres, associated with improved GP and patient education on skin problems.
A system of midwife-led care supported by six integrated care documents was developed at Taunton & Somerset Hospital according to Trust guidance on ICPs. An audit at 12 months showed that >50% of women can be Cared for by midwives alone. Sample documents for antepartum haemorrhage and suspected pre-eclampsia are presented.
Thrombolysis of appropriate and selected patients presenting with an acute ischaemic stroke within 3 h of onset with recombinant Tissue Plasminogen Activator (alteplase, r-TPA) can be implemented safely, reduce long-term disability, and is recommended by the National Institute of Health and Clinical Excellence and the Department of Health's National Stroke Strategy. We have developed an integrated and comprehensive pathway in order to achieve the above aims, which also provide guidelines for nursing in the peri-acute period and management of complications arising from the ischaemic stroke itself, from thrombolysis or from concomitant hyperglycaemia.
Heart failure (HF) is a major public health issue and acute decompensated heart failure (ADHF) is a leading cause of hospitalization in the USA. The United States health care delivery system is bound by regulatory agencies requiring strict compliance to key clinical indicators, which are publicly reported. Clinical pathway development is a systematic approach to managing health care that involves a high degree of collaboration between patients, physicians, nurses and various health-care team professionals. The University of California, Irvine Medical Center (UCIMC) developed an evidence-based multidisciplinary pathway for patients with ADHF. This clinical pathway incorporates universally proven assessment and treatment measures in ADHF. Adjunctive to this process are patient and nursing guides to the ADHF pathway. Utilization of this pathway has been shown to significantly impact clinical performance by early identification of potential negative clinical outcomes. Clinical pathways, such as the ADHF pathway, promote clinical excellence in caring for acute and chronic diseases states.
As clearly demonstrated in Dr Smith’s Letter to the Editor published in this issue of Journal of Integrated Care Pathways, just having a care pathway in existence, however well-designed, is not enough to ensure improved care to the patient. Over the past 20 years, I have seen innumerable examples of care pathways that appear well-designed from the perspectives of both content and layout, having little effect either way on the care delivered. On the other hand, I have also seen as many care pathways that by anyone’s standards appear poor, but that have been embraced by the local team and that have had a significant, measurable effect on the quality and efficiency of processes and the outcomes of care. This poses the question ‘does a care pathway have any real impact on improving care, and if so, what determines its effectiveness?’ Part of the answer lies in common sense. The most perfectly designed care pathway, if little understood and poorly used, can hardly be expected to make any difference to anything. On the other hand, a care pathway thoughtfully designed with the involvement of those whowill use it, that seeks to ease, coordinate and streamline the provision of the best possible care, and that provides relevant, regular and well-targeted feedback to inform and interest those same people, has far more chance of having an impact on process and outcomes. I have recently been contacted by a Publishing Director who is interested in the better understanding of what is ‘good practice’ when it comes to reviewing pathways. To date, a surprisingly little amount of effort or research has gone into this area. Some examples of pathway audit tools that consider issues such as the content and layout of care pathway tools and the mechanisms of organizing care include: the Clinical Path Assessment developed in the late-1990s by the Centre for Case Management (USA); the ‘badge of quality’; an integrated care pathways appraisal tool developed in 2002 by De Luc et al.; the Integrated Care Pathway Appraisal Tool (ICPAT) developed in 1999 by Wittle et al.; with the support of the Partnership for Developing Quality, West Midlands Regional Levy Board; the ICP Key Elements Checklist developed in 2004 by Croucher as part of a Masters thesis; and the Care Process Self Evaluation Tool (CPSET) developed between 2004 and 2007 by Vanhaecht as part of a thesis to obtain the degree of Doctor in Social Health Sciences. Venture Training & Consulting has developed and used two Care Pathway Quality Scorecards as an exercise over the past 10 years to help teams to ‘know a good care pathway when they see one’ and to decide what they want out of the care pathway that they plan to develop locally. However, none of these tools fully address the relationship between key characteristics of the care pathway and successful implementation. It is certainly possible to teach and to recognize quality content and good design of a care pathway. This supports a growing view that nationally developed and accredited, high-level care pathway maps/ algorithms and supporting care pathway documents, decision scorecards, guides, etc., that can be adapted and built upon for local use, are a valuable starting point. These high-level care pathways are in the most part uncontentious and can provide local teams with the information and confidence that they are implementing the nationally agreed key elements of evidence-based best practice. Guidelines, protocols and initiatives such as the UK Standards for Better Health and Care Bundles can be incorporated to inform evidence-based best practice. Variation can Jenny Gray MCSP SRP Grad Dip Phys, Managing Director, Venture Training & Consulting, Manor Farm Barns, Selsey Road, Donnington, Chichester, West Sussex PO20 7PL, UK.
The use of integrated care pathways (ICPs) to enhance quality and consistency of patient care has increased in the last decade. In two closely related studies, we first assessed the benefit of a new ICP for acute coronary syndrome in our district hospital, and secondly assessed the impact of ICPs in UK coronary care units, correlating with data from the Myocardial Infarction National Audit Programme, MINAP. The new local ICP produced statistically improved admission medication, with the chance of correctly prescribing aspirin increasing by 63% ( P < 0.002), and borderline increase for clopidogrel of 28% ( P > 0.10), and enoxaparin of 21% ( P > 0.06), in a completed audit cycle study totalling 100 patients. A national telephone survey showed that of 210 UK coronary care units, only 40% had an ICP in place, and this made no difference to either door-to-needle time for thrombolysis or to rates of discharge medication with aspirin, beta-blockers or statins. While these results fail to raise enthusiasm for implementing an ICP, other potential benefits of their use may be important such as optimizing data collection, improving consistency of care and unifying the different clinical teams in planning the care of the patient.
This article describes the way in which Catharina Hospital introduced clinical pathways to its workforce. The hospital, one of the largest non-academic teaching hospitals in The Netherlands, developed the first clinical pathway in 2004. Since then, clinical pathways have been presented as a strategic tool for improving care. In preparation for an organization-wide project, a team investigated and adapted the methodology as designed by the Clinical Pathway Network to the specific situation of Catharina Hospital. Staff were educated, which in return provided project teams with methodology and tools for development. Started small, the aim of the project is to achieve a snowball effect in the use of clinical pathways. Having started in 2006, six pathways are currently under construction, more of which are considered for development. An evaluation of the methodology and results in the summer of 2007, showed that the method was of great help in optimizing care processes and developing multidisciplinary agreements.
HIV is becoming more prevalent in the UK, and is being increasingly detected in asymptomatic women during antenatal screening. Taunton & Somerset Hospital wrote an ICP document for the management of HIV in pregnancy according to their Trust policy, and it is presented here.
For the third year running, throughout the Care Pathways 2008 conference organized by Healthcare Events, posters were displayed, and poster presenters were available to talk about their displays and answer questions. This formed a valuable and interesting part of the annual conference, giving ample opportunity for sharing and dissemination of best practice and ideas. Eight posters that were displayed are reproduced below along with summary reviews covering the projects’ main aims and objectives, methods, results and conclusions.
In supporting teams across the UK to develop care pathways, I have discovered that the promise of transparency and the opportunity for consistently measuring success strikes fear into the hearts of many. Frank discussions reveal that there is uncertainty about who will gain from transparency and how. What will professionals who have historically held the balance of power by keeping what they do shrouded in mystery, gain from sharing this information? What shifts and changes to services will managers and commissioners make based on their interpretation of this information? How will politicians, so skilled in manipulating information, use this new source of knowledge and insight? Knowing more or different things about the care of patients has always been a fundamental part of the games played by each party; how would these games change if everyone had all the information? If we honestly want a patient-centred health service, based on evidence, with services fit for purpose and equality of access, then why would we be afraid of transparency? A knowledge management framework based on transparency of the patient-centred end-to-end process of care (the business of health care) provides:
Throughout the Integrated Care Pathways 2007 conference, organized by Healthcare Events, posters were displayed, and poster presenters were available to talk about their displays and answer questions. This formed a valuable and interesting part of the annual conference, giving ample opportunity for the sharing and dissemination of best practice and ideas. The previous issue of the Journal of Integrated Care Pathways featured 13 of the posters and the remaining three are reproduced below along with summary reviews covering the project’s main aims and objectives, methods, results and conclusions.
The result of any Lean Sigma project should be a lower-cost, more effective and efficient operation focusing on the voice of the customer. This is achieved by reducing various types of waste, improving quality and finding more effective ways of working. Ultimately, the customer experiences a superior service. As most Six Sigma projects are selected based on their return on investment (ROI) and Lean projects are implemented to drive out waste, returns are measured at the end of the project. To have the same or improved level of performance 100 days after the project has finished and the Lean Sigma professionals have moved on is often the all-too-elusive objective. Why is this so hard to achieve? Sadly, reality is that often benefits or savings are very localized within
INTRODUCTION The previous issue of the Journal of Integrated Care Pathways featured the write-up of the Clinical Excellence Conference 2006, during which three main themes emerged surrounding the challenges for health care today: implementation of change and improvements, communication and dialogue and transparency. The following two case studies are examples of where teams have used the transparency gained through electronic activity-based process mapping and performance management to accelerate and implement change, and to achieve tangible and measurable high levels of adoption and improvement. The software used in both cases to capture, analyse and communicate the processes was Nimbus control-ES. 1
Travelling around the country observing the approaches of different organizations and listening to people talk about their experiences of implementing change initiatives, one message becomes clear. Making the strategy a reality is a great challenge, one that is seldom perceived by the majority to have been achieved. Even in cases that boast impressive initial achievements, further down the line there is rarely evidence that the services continue to improve, and that the early motivation and drive for improvements have been sustained. Changes both in frontline staffing, management and leadership, as well as the unsettling pressures of organizational mergers and other cultural changes are often cited as reasons for this failure to sustain results. So what can we do in the future to embed the changes into everyday practice and behaviour and to prevent the fast start that fizzles?
Clinical pathways, also known as care pathways or integrated care pathways, are used worldwide to make care processes transparent and organize care around patient needs. Although this is in international use, it is still unclear why pathways sometimes work and sometimes do not. To better understand how pathways work, there is a growing need for paradigms or organizing concepts. Different quality and health-care management gurus have developed frameworks to better understand how certain processes or methods work. This paper will provide an overview of several frameworks and integrate them into Donabedian's Structure–Process–Outcome configuration. In view of this configuration, the care process organization triangle was developed. In this paper, we will describe the three cornerstones of this triangle by integrating the literature on clinical pathways. The care process organization triangle is only one model, but as Deming described it: ‘Some models can be quite useful’.
